Provider Demographics
NPI:1720039522
Name:GREGORY, STACY (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD
Practice Address - Street 2:STE. 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2300
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:713-458-4229
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39354207L00000X
OH096694207L00000X
TXP9358207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3145019Medicaid
50025230OtherPASSPORT
IN000000635467OtherANTHEM
IN107356OtherSIHO
TXP01444554OtherRR MEDICARE
129703800OtherUS DEPT OF LABOR
TX339125201Medicaid
GR4317491OtherMEDICARE
3730868000OtherPASSPORT ADVANTAGE
TX8ER269OtherBCBS
IN134960MMedicare PIN
3730868000OtherPASSPORT ADVANTAGE
50025230OtherPASSPORT